Psych2LKIT

Category: Adderall Withdrawal

A topic gets sensationalized, everyone jumps on it and we forget all else. Like my wisecrack about the airlines being like the drug companies. Right now, a hot topic is demonizing the use of opiates. Yet the third leading cause of death is doctor error …sometimes writing the wrong medication.

They are changing the name of my antidepressant, Brintellix to Trintellix because docs and pharmacists were getting Brintellix confused with something else….

Gosh, I had just gotten my pharmacist and my doctor accustomed to the original spelling. As if life wasn’t confusing enough. Instead of further restricting people’s access to pain medicine they should make those doctors slow down and take remedial medical courses after an incident of physician error, as I’ve suffered a few of those and walked away from a lucrative lawsuit. (See: Tardive Dyskinesia, Failed Foot Surgery)

Someone finally took on this topic in my beloved New York Times. It was about the benefits of learning, especially in middle age; made easier because most contests and competitions are over by that point in life and NO ONE IS WATCHING.

Apparently, making a commitment to get good at something in schoolchildren and highschoolers can cause anxiety because the kids are so worried about how they look. Or if they seem to be smart. Key word: Seem.

Later in life, there’s less pressure and more benefit. A disciplined effort at improvement at something, whether it’s reading the paper, jewelrymaking, coloring books, sports, collecting shells or birdwatching involves frustration-the old two steps forward, one and a half steps back. But that’s ok.

Here’s the benefit: You seize time and make it yours. You are, by practicing or learning, getting better at SOMETHING, while other stuff, like physical strength and memory and for some, motivation, are fading away.

Yes there are all sort of studies about how learning stimulates blood flow to the brain, always a good thing. All of that being said, I have my words for you this week. There are so very many I can’t keep up. It’s campaign season and those folks are making it up as they go along too.

Atavistic: Ancient, Ancestral.

Peripatetic: Moving around like a Nomad, from place to place. I wrote an article once about Sonic Youth and in the intro my editor called me Peripatetic and I was too embarrassed to ask what it mean.

Hawkish (this always comes up in association with Hilary) it means to threaten or be belligerent about foreign policy.

Waggish: Mischieviously funny.

Sanguine: To be optimistic in a sad situation.

How does this relate to Bipolar Disorder, Depression and or Tardive Dyskinesia or other side effects that come with meds? It’s a blog to take you away from all that, like a magic carpet from Mosul, if you will.

It’s mental health month and there’s some hashtag but aren’t we just preaching to the choir here? I’m much more interested in DBSA’s advocacy platform which will help us mobilize in numbers that matter.

This is from “Under The Influence.” It’s by a doctor who writes prescriptions for buprenorphine. For pain. For addicts temporarily but for pain patients indefinitely. She wanted to speak out.

This practitioner calls Suboxone a ‘stealth’ drug. Read it. You’ll see. There is not a lot of press coverage on the use or lack of use on this drug. There is an alliance organization that matches people up with doctors but it says the limitations on how many patients a doctor can treat at one time…waiting lists, they say it’s easier to just get placed in a research study.

Doc, I need some help getting off this stuff.”

My new patient Marshall*, a pale 63-year-old man who lugged around a portable oxygen tank for his breathing problems, had been stuck on pain pills for years. Sharp pain from a gruesome factory injury to his shoulder 25 years ago had evolved into a nightmarish, shock-like nerve pain down his arm to his fingertips. A succession of medical treatments culminated eight years ago in prescriptions for daily use of oxycodone.

It had worked well at first. But after a few years, he descended into a continuous state of opioid withdrawal. At best, he felt mildly anxious and tremulous. Two hours after each dose, he would skid into a wretched state of sweats, gut-knots and dread. His whole body screamed with a pain unrelated to his injury. He craved relief from the next dose.

Sometimes, out of desperation, Marshall would take the next dose early. In exchange for the immediate comfort, he would accept a guaranteed anguish starting days before the next refill was due. His previous doctor had attempted to help by increasing his dose. Symptoms would subside for a month or so, then return with a roar, growing ever more intense. His arm pain had been relegated to a minor annoyance.

The best solution to his cyclical torment was clear to me. I would transition him to a medicine called buprenorphine.

Opioid task forces springing up in the US at the local and national level have begun to cast a spotlight on the surging opioid epidemic and its deadly consequences.

Unfortunately, a sharp focus on the target of opioid “abuse”—non-medical use of pain pills that has led to addiction in an estimated 2 million people in the US, and to heroin use in 1 million—misses a fundamental problem of a much larger scale. Roughly 17 million US adults living with chronic pain are prescribed opioids for daily use. Many, perhaps most, are not thriving.

Yet without these pills, many find life intolerable. Neither patients nor doctors know what to do about it.

A readily available solution—buprenorphine—is a secret weapon largely still waiting to be discovered. And President Obama’s strong emphasis this week on medication-assisted treatment—especially buprenorphine—in his announcement of his plan to combat the opioid crisis, is therefore particularly welcome.

As a family physician, I am in the trenches with patients battling chronic pain. I have seen Marshall’s story played out again and again. Sometimes people are referred to me for help after limping along on opioids for years. Buprenorphine is often the best choice.

Some make the transition seamlessly. Others traverse a rocky road that tests their mettle. Ultimately, most arrive at our intended destination, experiencing a calm normalcy they can hardly believe. A tolerable vestige of their original pain is still present. Opioid withdrawal and its accompanying super-pain, sometimes known as “opioid-induced hyperalgesia,” have vanished.

Patients describe a sense of release from a box or a locked cage. One said, “I felt like a little troll trapped inside a bottle, a horrible feeling. And now I’m free. I’m absolutely thrilled.”

Buprenorphine is better known by one of its brand names, Suboxone, an under-the-tongue film laced with naloxone to deter non-prescribed use. In 2002, buprenorphine–alone or combined with naloxone—was approved by the US Food and Drug Administration as a treatment for people like another of my patients, Luke.

A gentle giant in a black leather jacket, Luke is a 20-year-old convenience store employee who casually enjoyed a Percocet now and then while hanging out with friends. Then he began enjoying one for relaxation daily after work, “like having a beer or two.” Eventually he found himself entangled.

To avoid the agonizing withdrawal symptoms, Luke began spending most of his income buying pills illegally. He risked arrest. He arrived late for work. He could not afford to move out of his parents’ home. The drug’s negative impacts on his life landed him the diagnosis of opioid use disorder—the latest medical term for the condition most people recognize as addiction.

Buprenorphine is often, in my experience, like a magical key that frees people from their seemingly inescapable dungeon. It is an opioid medication with a unique profile that fits the lock precisely. It blocks withdrawal symptoms and craving. There is no drug “high.” Patients trade sluggishness for a fresh energy. Best of all, the hovering risk of overdose death vanishes.

Buprenorphine was developed decades ago and approved by the FDA in 2002. Yet it remains nearly invisible, despite its potency against a fiendish trio of adversaries: withdrawal symptoms, craving and overdose death. That’s why I call it the Stealth Medicine. It is hidden behind the term “medication-assisted treatment,” which also includes methadone and naloxone. Buprenorphine is the only one doctors can use to treat opioid use disorder in their patients with chronic pain.

Any doctor can prescribe buprenorphine for opioid use disorder, after undergoing a brief training required for authorization, known as a “waiver,” from the Drug Enforcement Agency. Only a tiny minority obtain the waiver, however. Due to federal rules, the number of patients each one can treat is strictly limited—to 100, although President Obama’s plan will increase that to 200—and other prescribers (nurse practitioners and physicians’ assistants) are not eligible for a waiver.

Ironically, there is no such bottleneck on access to the opioid pain pills involved in the deaths of 19,000 people in the US in 2014.

There are strict rules constraining use of the waiver. For one thing, the patient has to have a diagnosis of opioid use disorder. This diagnosis implies a stark but false distinction between “legitimate pain patients” like Marshall and “drug abusers” like Luke. The same dreadful craving afflicted Marshall, who lost his struggle to use pills as prescribed, and Luke, who never had a prescription. Buprenorphine brought relief to both.

“Off-label” prescribing for chronic pain is perfectly legal without a waiver. The limited research available supports this practice: It shows that a switch to buprenorphine improves pain and quality of life.

But here’s the catch: Without a diagnosis of opioid use disorder, buprenorphine is rarely covered by insurance. With the diagnosis, it usually is. Under Obamacare, insurance companies must provide coverage for treatment of substance use disorders. Luke pays roughly $10 per month for this otherwise pricey drug, which can run to hundreds of dollars without insurance.

The case of Marshall, the patient with arm pain, illustrates the awkwardness of this situation. He never once used opioids for euphoria or relaxation. He never committed a crime, never harmed a relationship with family or friends, never even pressured his medical providers to obtain more of his drug. A diagnosis of opioid use disorder was a stretch. But I made the diagnosis based on his unwelcome craving, and his inability to resist taking doses earlier than scheduled despite known consequences. This diagnosis allowed him access to this life-saving treatment.

Other insurance quirks can create frustrating obstacles. Lily is a trim and perky middle-aged homeowner, a responsible caregiver to two grown children with special needs. For years, Lily had been prescribed oxycodone for arthritis in her spine. She described what happened.

“The longer you take them, the more they make you hurt. It creates pain. You get tolerant to it. And then you think, I’ll take just a little more, and then you take a little more, and pretty soon you hurt worse than you did before you started taking them. The brain creates this fake pain, a magnified pain that really isn’t there. In between doses you would get a depressed feeling, because you knew you weren’t supposed to take another dose, but you hurt, and this becomes cyclic. When you take buprenorphine, you get your whole mental stability back. You don’t have to worry about driving or feeling dopey. It gives you your life back on a plate.”

Since starting buprenorphine for opioid use disorder, Lily had begun walking two miles a day. For two years, she often had no pain at all. Insurance coverage was in place.

Then the insurance company discovered she was not enrolled in a chemical dependency program. She was thus deemed noncompliant with their requirements for buprenorphine coverage. Payment for the next refill was denied.

A formal treatment program would be overkill even for a patient like Luke, the convenience store employee, although he could certainly benefit from having a counselor. But what about Lily? Such a program would be an irrelevant intrusion.

I re-prescribed buprenorphine for Lily, this time using a diagnosis of pain. Coverage was denied. I appealed. Ultimately I talked with the medical director. He politely informed me, “Buprenorphine is not a good medicine for chronic pain, so it is not an option for your patient. But we will cover oxycodone.” Lily has since switched to a more flexible insurance company.

Robin, a stylish business executive, got coverage because she met criteria for opioid use disorder; after discovering buprenorphine’s unique effectiveness for her fibromyalgia, but before she found me to prescribe it, she had guiltily resorted to buying it off the street.

But what about Sally, a sweet 50-year-old lady on opioids for many years after an injury to her lower back? In a classic example of opioid-induced hyperalgesia, she described intolerable shoulder and neck pain after a demanding night at the community center playing bingo. She has always been meticulous about using her pain medicine as instructed, so she doesn’t meet criteria for opioid use disorder. But with exaggerated pain sensitivity, she might still benefit from buprenorphine.

The tides are turning. Many national leaders are now recognizing opioid addiction as a disease and not a crime. Now we need a more nuanced view of the challenge people face when their chronic pain is poorly controlled by opioids. Many struggle to use their prescribed pain pills as directed. Whether they succeed or fail, buprenorphine may improve their quality of life.

A sea change would be possible if millions of patients with chronic pain were switched to buprenorphine from daily pain pills. This would dry up the flood of opioids leaking out to the streets. Fewer young people would find pills and be tempted to try them. Fewer still would graduate to a gritty life of heroin use, or risk a death from overdose.

Doctors, patients, insurers and policy makers: Take note.

*Patients’ names have been changed.

Lucinda Grande, MD is a board-certified family physician who practices in Lacey, Washington. She specializes in chronic pain and addiction medicine. She has prescribed buprenorphine for opioid use disorder for four years, and currently prescribes it to 70 patients.

This relates to all the hysteria about opiates and the lack of attention paid to the treatment of chronic pain. Yes, Deb at CDC, noncancerchronicpainlivesmatter.

Prince may not have died in vain. From reading articles I found he and I had a lot in common. Chronic pain from too much over exertion. Mine is in my back. I am a responsible, steady, minimalist user and have reduced my dose by 2/3 as well as frequency. But the side effects are terrible and have finally caught up to me. How does this relate to Prince? Well, there is a guy who has stuck his neck out on the line, a maverick in the treatment of chronic pain using Suboxone and or Buprenorphine. Less side effects, no intoxication like the quick acting Vicodin, Tylenol 3 and 4, and Percocet and those lovable blues, the oxys. Those get ya high. Hook you in. I know first hand because I got off of them. Prince’s people had contacted Howard Feldman, whose treatment center is outpatient “Recovery Without Walls” For anyone who has been in 12 step groups, the ‘abstinence only’ idea is great in theory but what do you do for the pain once you get off the pills? According to the literature and the studies and conclusions of his, there have been outside pressures restricting the use of this drug. A doc has to be licensed and can only prescribe it for 100 people. I found out yesterday that my hoity toity upscale pain clinic doesn’t have a license for it and my questions about a healthier non opiate alternative were met with skeptical frowns. Dr. Kornfeld’s son, Andrew, flew out to Paisley Park with an initial dose of Buprenorphine in his pocket to show Prince that he wouldn’t be dealing with terrible pain but Prince had one last go before the life saving mission was able to save him from himself. Basically guys, Buprenorphine is Methadone light, saves lives…by 75%, reduces disease transmission and if it had been more widely available instead of an insider’s secret he might still be alive today.

What do I do? In my next post, I’m going to show you the letter I am writing to the good doctor to try to find someone here in South Florida. It’s intimate and has awful details but maybe someone will relate to it.

here are some ideas on handling side effects of pain meds and some stuff I do to relieve pain other than just pills. You might find some of this helpful but I have questions too about pain management I hope someone can answer. I’m up against it. And the CDC is tightening up again. Friggin alcohol kills more people. No one is addressing the pain problem driving people to the pills in the first place.

Don’t get wrong idea…I’m on anti-inflammatory diet, alkalizing supplements, do pilates class, pilates at home on the mat, drink tons of water, get other types of exercise, use the non narcotic pain patch and anti inflammatory alcohol based tonic called Pennsaid before laying down on a bag of ice.

HERE ARE MY QUESTIONS…DOES ANYONE KNOW?

I’d like to change to suboxone because the big secret is that it works for more than just opiate cessation, it helps the pain. The bioavailability is such that you can get by on really really low doses. lower doses than a transfer chart would suggest!!!!! But doctors are limited to only having 100 pain patients on Suboxone. WHY? Does anyone know?

I read yesterday that Obama is pushing to raise that limit to 200 per doctor to deal with the heroin epidemic and pain pill problem.

Can anyone answer some of these questions for me or offer insight into suboxone for pain management? If they cut me off, I’ll have to visit Mexico and Cuba after all. Even though Cuba will be open for cruise voyages on May 1, I wasn’t planning on going because I already live at the beach and drive an old car. hehe

If you have been following this blog for a while you might think I’m married to a life of battle against the ‘powers that be.’ Back when I was on Tumblr I posted a lot about my lighter side, jewelry making, pilates, and gourmet cooking, one of my passions. We have this store in town called Penn Dutch. They have the best, most highly trafficked (this makes for fresher fish because it’s always being replaced by new hauls) fish counter I’ve ever seen. Yesterday they had 9 Oz LobsterTails from South America, not Australia. They carry a Brazilian fish called Branzino that I’ve never heard of.

Yesterday I bought a fish native to here, South Florida, called Pompano. (pictured) it’s only 6.99 a pound, you purchase the whole fish and get two 6oz filets out of it. They filet it for you. What I do is buy coconut milk, fresh mint, and chili paste. I add more splenda to the mixture and heat it up. Then I put dissolved cornstarch in it and pour it over the fish and put it in the oven. I make steamed vegetables and rice, and the extra coconut milk sauce goes good over both. Mike my husband really likes this.

I had to stand at a fish counter with a number tag in my hand for 1/2 hour as this store is crowded. But that’s what makes the fish counter so fresh. Nothing sits there very long.

I started blogging with Tumblr. I got hundreds of follows right off the bat. Many in the eating disorder community. Then I switched to WordPress without knowing anything. Somehow this led to me researching and writing a story on something I used to be cynical about (who, me, cynical? No, tell me it’s not true! hahah) The DBT class is held at the outpatient facility of the public hospital in this area. It’s called “Rebel’s Drop In” and is part of the reason why my blog has that theme.

Anyway, there is a long running personality problem with the gal that runs it. I wrote a flattering article about her place and she said stuff that I wrote down. My deadline loomed and when she was on vacation I emailed her two versions. She used her Mindfulness as a weapon and attacked me for bombarding her with emails. Hurt, I stopped asking her for information or offering her final editoral approval. (Sean Penn had given Chapo final editorial approval and apparently it’s a no no) Anyway after she attacked me for sending multiple versions to her for her approval I just backed off. I took her name out of the story as well as the center, the donor’s name and the hospital system if’s affiliated with. When I saw her later she said she was really unhappy with the whole experience and it was the most bizarre that she’d ever had. She still won’t speak to me and she’s the project director as well as one of the DBT therapists.

The only thing between me and DBT is money and this woman.

I want to take it. Does anyone know what the copay?

I did a research story on it for NewLifeOutlook Bipolar read the original book CBT by Linehan and think it could help me with certain faulty thoughts and fear/guilt driven behavior that results in misplaced priorities, loads of stress, Etc.